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The personal blog of Peter Attia, M.D.

Two choices

Two choices

I recently gave the keynote address at the faculty retreat of the Pennington Biomedical Research Center (PBRC) in Baton Rouge, LA.  When Eric Ravussin invited me, I could not have been more honored.  Folks not familiar with PBRC may be familiar with some of its esteemed alumni, including Drs. George Bray and Claude Bouchard, both of whom I was lucky enough to sit with and discuss everything from the death of Dr. William Stark to esoteric mutations in the MTHFR gene, the possible drivers of variable weight gain in Dr. Bouchard’s famous identical twin overfeeding study (the answer will be published soon, but he shared his data with me), and the best possible experiments that could be done to test the hypothesis that sugar may be more metabolically harmful than simply failing to provide nutrients.  All in all, it was a remarkable afternoon with a room of exciting folks.

The day was only made better when Gary Taubes and I gave a pair of talks that evening to a group of 40 to 50 very sharp physicians at Baton Rough Medical Center examining the evidence in support of the two central tenets in (modern) nutrition:

  1. Fat balance is determined solely by the number of calories ingested;
  2. Saturated fat and dietary cholesterol cause heart disease.

Gary spoke to the first and I to the second. In both talks there was a common theme, or thread: the evidence supporting our current dietary guidelines could, and should, be better.  Else, we run the disastrous risk of the guidelines being incorrect.  In other words, have we done the best work possible yet?

In discussing this with a friend (much smarter than me and a much better communicator), he said the following, “We would never build and fly airplanes without understanding lift, thrust, drag etc. But we are building diets without knowing these fundamentals.  We are building diet-planes with no flaps, no tail, and possibly no wings.  Then when they crash, we blame the pilots.”

Obviously, I’m biased.  And not just a little bit. I’m biased to the tune that I’ve bet my career on the idea that it’s worth doing better science to resolve this.

What kind of pushback do I get?

Most of the resistance I hear to this notion falls into two buckets:

Proposition 1: The science is settled.  The idea that obesity could be a function of anything other than caloric balance is silly.  Case closed. (Call this the “Treatment is fine” proposition.)

Proposition 2: The science is good enough, and the “prescription” (i.e., the dietary guidelines) is clear.  The bigger issue is that people can’t follow them, whether a result of their own gluttony or sloth or food manufacturers. (Call this the “Treatment is good enough, but people don’t adhere to it” proposition.)

There are, obviously, many variations on these themes.

Anyone who has read the fine print in this blog may recall that in a previous life I was a member of the Corporate Risk practice at McKinsey & Company. Risk was a natural fit for me (along with healthcare, the other practice I was a member of) when I joined McKinsey for a couple of reasons.   First, risk is a very quantitative field, and I love mathematics and mathematical modeling.  Second, I tend to “think” in risk terms naturally.  (This does not imply, of course, that I don’t make poor decisions – I do – but I’m usually aware of the risk when going into said poor decisions.)  If confronted with a choice where the answer is not clear, I tend to think of “downside risk” and “upside risk.”

For example, consider if I should elect to buy life insurance or disability insurance (versus, say, car insurance, which is mandatory).  There is a real cost of doing so, especially disability insurance, since the actuarial risk of being disabled is higher than the risk of dying.

So I might ask myself, what is the worst possible outcome, and how can I mitigate against it? In this case, dying or being disabled without leaving my family financially secure is a far worse outcome than, say, spending $30,000 over 30 years “unnecessarily” (i.e., not dying, and therefore not needing to have spent the money). This is an example of mitigating downside risk.

Investments work the other way (I won’t complicate this with a discussion of financial options like derivatives, where you actually have both uncapped upside and downside risk).  If you’re willing to invest $X (and presumably this is “disposable” so you’re willing to potentially lose it, but your loss will be capped at $X), the upside probably depends on the amount of risk you’re willing to take.

How does this relate to nutrition science?

Think of our nutrition situation as a combination of the two examples above. If we do nothing – i.e., if we assert that proposition 1 and/or proposition 2 are correct and that doing better science is unnecessary – what is the upside?  Well, we’d get to save the significant money that needs to be spent on the science.  That’s a true upside.  But, what about the downside? We’d possibly miss out on a better “treatment” and likely spend more in a few days treating metabolic diseases than would be saved exploring a better treatment.

It’s impossible to fully quantify the economic cost (never mind the social cost) of metabolic diseases, but let’s take a conservative estimate, as follows:  The direct cost of obesity (not including indirect costs, such as lost productivity) is between $190 and $200 billion per year in the United States.  For diabetes, this number is closer to $220 billion per year.  So, if the prevalence of obesity in the United States were reduced from where it is today, 36-37%, to 15% (what it was the year I was born), that would translate to a direct reduction in healthcare spending of over $110 billion per year.  Do the same math with diabetes, and it’s now a combined direct cost savings of over $275 billion per year.  This says nothing of heart disease and Alzheimer’s disease, but you get the point.  If you add it all up, we spend about an extra billion dollars per day (not a typo) treating the incremental cost of metabolic diseases beyond 1970’s levels.

So, imagine you had an opportunity to spend a billion dollars on research, to challenge proposition 1 and/or proposition 2, should you do it?  Even if the chance of making any progress was 5%, it’s still a very compelling value proposition, isn’t it?

What’s at the root of this debate?

I think it comes down to an error in logic.  Think of it this way, if proposition 1 is correct and proposition 2 is correct (these are not mutually exclusive), what should our response, as a society, be?

Consider an analogy.  Imagine there is a deadly disease taking lives at an unacceptable and growing rate.  The medical establishment says, “Here is the treatment,” but despite the treatment, the incidence and prevalence of the disease keeps climbing. There are only two logically consistent conclusions:

  1. The treatment doesn’t work, and/or
  2. Patients don’t take the treatment (even if it does work).

If the former, we need a new treatment.  This is obvious. But, if the latter, we can’t just blame the patients.  We need to know why they aren’t taking the treatment:  Is there a nasty side effect that got missed in the FDA approval process? Is it too expensive? Do doctors not prescribe it properly?

Regardless of the answer, it’s not acceptable, is it? Now, imagine you’ve had 40 years of tweaking variables around option #2, but the situation is only getting worse.  How does this impact your Bayesian probability calculation of option #1 being correct?  It must go down. This doesn’t mean option #1 is incorrect, but with each passing day of failure, it appears less likely to be correct.

Now factor in the upside and downside risk calculation we went through earlier.  How long is it acceptable, in the face of conditional probability, to ignore the possibility that option #1 is incorrect?

One more point…

We (myself included) are pretty quick to blame “industry” for the situation we’re in.  This line of reasoning got a great deal of attention recently with the publication of two very interesting and provocative pieces, one in the New York Times and the other in Mother Jones, both absolutely worth the read, and both quite upsetting.

But, I would argue that shy of knowingly suppressing evidence which, admittedly, may be going on in some areas, we can’t really fault the food industry for making their products addictive, can we? Isn’t the CEO of Coca Cola accountable to his shareholders?  Isn’t the best way to increase earnings per share (the metric to which shareholders and Wall Street rewards him) to have a product that customers want? A product that tastes really good? A product that makes you want to buy it again?  Should the CEO of BMW make cars that drive slower and use less gasoline, if it meant selling fewer of them? Not according to those who hold him accountable.

I would argue further that this is the job of the scientific community.  Back to our original argument, if all calories are equal, then the favored-by-many rhetoric of “all things in moderation, including Coke” makes perfect sense.  But, if sugar is metabolically harmful and even addictive, this isn’t really true, is it?

You can’t have it both ways.  If sugar is addictive, then the first central tenet of nutrition isn’t actually correct.   So now we’re back where we started.  Are we going to continue to assume that these tenets are correct (the treatment is correct) and blame the victims (they can’t follow instructions) or industry (they make the disease too pleasurable)?

I don’t know about you, but to me 40 years of this logic seems like enough.  I think it’s time for a new approach.  It’s worth the risk.



About the Author:

Peter Attia, M.D., is a physician in private practice in NYC and CA. His practice focuses on longevity and healthspan. His clinical interests are nutrition, lipidology, endocrinology, and a few other cool things.


  1. Matt  March 28, 2013

    I’m so glad you brought up Bayes’ theorem. I was most of the way through the post and couldn’t wait to get to the comments to point out that even if we do some rough Bayesian estimate we see that it is quite unlikely that 1 is correct. But you beat me to it.

    • Peter Attia  March 28, 2013

      That’s what I love about the readers of this blog. One step ahead of me.

  2. bill  March 28, 2013

    Bravo! Let’s get on with it!

  3. JF  March 28, 2013

    It’s interesting to note that the use of Cost-Benefit Analysis is de facto law, via Executive Order 13563, for basically all federal regulatory agencies in the United States. Cass Sunstein has argued that the burden of proof for reasonable legal challenges to administrative policy depends on whether agencies can be shown to have done CBA calculations in an arbitrary manner. If you can make a plausible case that some agency decision did not use relevant data available at the time of making a given decision, then that should be a basis for legal challenge.

    This is all the more reason to do the research you are recommending, because in the absence of new research, regulatory agencies can continue to defer responsibility, since all the existing science supports their (bad) decisions.

    Although it is true that corporations are most accountable to their shareholders, we can still ask the question: should they be? If we think that the corporate CEO has blameless liberty in the absence of government regulation, they we are putting a halo on her blind pursuit of self interest. It may be the case that the best way to actually get corporations to restrain their behavior is through government regulation, but that shouldn’t entail that they would still have moral obligations in the absence of such regulation. Or, we may just think something like wrecking the health of the population is bad enough to justify strict liability.

    I think you mean “tenet” of nutrition. Although a tenant of nutrition would be intersting. 😛

    • JF  March 28, 2013

      Sorry typos. Just correcting the worst one I just made: I meant to say that the absence of regulation should not mean that there are no moral obligations.

    • Peter Attia  March 28, 2013

      Well you’re certainly asking the right questions, and to your last one (re: shareholders), that is for society to decide. But until they do, and the metrics are changed, we should not assume dogs won’t bark and bees won’t make honey. The key, as I suggest, is better defining the scientific understanding. Great points, though.

    • jw  March 28, 2013

      The assumptions used in government CBA always assures that the conclusion of the analysis “proves” the political outcome desired. GIGO.

  4. KevinF  March 28, 2013

    ” esoteric mutations in the MTHFR gene,”

    Ahem, I hope esteemed scientists don’t pronounce that the way I’d pronounce that.

    • Peter Attia  March 28, 2013

      Don’t worry, Kevin, it’s pronounced “M-T-H-F-R” …

  5. Danny Lennon  March 28, 2013

    Super post Peter, very well communicated.

    I think it is really valuable to take a step back and look at just how different nutrition-related disease is dealt with in comparison to any other area of modern medicine.

    It amazes me how some people can be so steadfast in their beliefs on this, despite the constant failure for anything to improve. We know more than ever before, have more resources than ever before, we spend more than ever before, yet disease rates are increasing. The prescription is wrong.

    • Peter Attia  March 28, 2013

      Or at least it there is enough evidence suggesting this…

    • Jaime Weis  April 21, 2013

      I’m not sure I find it surprising at all. I feel like I see more areas of life where thinking is entrenched despite consistent bad outcomes than I see areas where thought processes are carefully considered and outcomes are consistently good. If you say something loud enough and long enough, right?

  6. Scott  March 28, 2013

    Great post as always! Two thoughts:
    1. In reference to the twin studies, are you referring to the bmi discordant monozygotic twins studies? I’d be interested to hear your take on mitochondrial function as a driver of obesity (which I think was what these studies were suggesting).
    2. While food executives might not have “knowingly suppressed evidence,” this seems like an unnecessarily heightened standard. “Should have known” would probably be enough for a claim of negligence. Although I imagine any systemic change would be much smoother if Big Food were exculpated from any liability.

    • Peter Attia  March 28, 2013

      1. No, different studies.
      2. Agree, in reality the far more likely flaw than “knowingly suppressing harmful information” is “creating enough doubt that the issue is viewed as unresolved in perpetuity…thereby permitting the status quo to remain unchallenged.”

  7. Gareth  March 28, 2013

    Thinking in terms of motivations and resistance to change. The food producers will not necessarily be the amongst the losers in any massive dietary change in our society, they can make profit from food either way. It is hard to see how pharma will not be hurt by a less sick population in the long run. So maybe it would be wise to play to the food industry and be very wary of pharma.

    • Peter Attia  March 29, 2013

      Gareth, I think you make an excellent point! If the food industry is malleable enough to morph to emerging science AND the public demands a product in line with that…they will figure out a way to make it taste and good and be profitable.

    • jake3_14  March 29, 2013

      Processed food companies would be devastated by consumers’ return to traditional (pre- WWII) ideas of nutrition. Just look at the name of the industry: *processed* food. If you sell food in its natural state (or close to it), profits are paltry, due to spoilage and the need to make basic food affordable to your customers. Consumers demanding fresh, real, nutrient-dense food destroys their business model.

  8. Tuck  March 28, 2013

    “1.The treatment doesn’t work, and/or
    ” 2.Patients don’t take the treatment (even if it does work).”

    There’s a third optoin, which I think is what is in fact happening:
    The treatment is counterproductive, not just ineffectual; and the patients are taking the treatment.

    • Peter Attia  March 29, 2013

      Yes, there are a few options here. I think your option is sort of a subset of #1 or maybe a hybrid of 1 –> 2.

    • Maxine  March 29, 2013

      I absolutely agree. The US government food recommendation of 6-11 servings of grain a day will most certainly produce bad outcomes if followed, sooner or later.

  9. Mark B  March 28, 2013

    First great post. Doing the math just makes it more obvious that something needs to be done.

    I think your analogy with Coke is a little flawed though. I don’t think anyone who buys and drinks coke thinks it is good for them. I think the bigger problem is the government and grain industry pushing and advertising how good grains are for you when there is continually mounting evidence that it most certainly is not good for you.

    Given the correct information gives people a greater chance to make the right decision. I can’t tell you how many paleo success stories have this as an underlying theme. How they tried everything people tell them to eat more grains and kill themselves on the treadmills and stair climbers.

    • Peter Attia  March 29, 2013

      Mark, do you mean this is my first good post? 🙂 I’m glad I’m sticking with it long enough to write a good one! I agree that few would think Coke is “good” for them. But most people, including health professionals and policy makers, since living under the 2 tenets I described, simply revert to the “empty calorie” position. This is a slippery slope, though. When one posits that the only problem with a Coke is that it delivers 40 gm of non-essential calories in the form of sugar, moderation becomes the obvious answer. But moderation may not work for the average person, especially if the product is, for example, potentially addictive. And what if it’s worse? What if, in the quantities delivered, it’s actually metabolically harmful?

    • Heather  December 16, 2013

      Just a lurker here. I spent a lot of time in the forums on a Fitness/Calorie tracking website. There really are people out there who think you can eat 2000 calories of sugar a day and be perfectly fine as long as you’re still taking in less calories than you expend. It’s sad, just sad. (I can gain weight undereating calories if my carbs are high and crappy enough)

  10. jw  March 28, 2013


    (Better yet, podcasts and slides?)

  11. Andy Lopez  March 28, 2013

    I like how you posit the “only two logically consistent conclusions” then fail to posit the third logically IN-consistent conclusion that is the actual reality: The treatment doesn’t work BY DESIGN because of the long ago realization of the massive profits that can be made by sacrificing of the health and lives of a gullible and intentionally uneducated public by establishing policy that promotes toxic “foods” that cause diseases treated by the medical establishment with drugs from the pharmaceutical industry.

    The problem with your analysis and math is that expressed as a percentage of total US GDP of 16 trillion per year, even the higher total cost of “a billion dollars per day” totaling 365 billion per year is only around 2.25 percent of the country’s entire economy.

    Since there’s comparatively little and less money to be made from healthy people, I assert that a sick and diseased public adds MUCH more to the economy and corporate profits than it costs.

    • Peter Attia  March 29, 2013

      Andy, before you dismiss saving nearly $400 bn per year, put it in perspective, especially if we include the other diseases I did not include (like AD). Let’s assume this number is closer to $500 bn (still “only” about 3 or 3.5% of GDP), that’s nearly 20% of total healthcare spending, which is now about about 18% of GDP. How many other opportunities are there to save half a trillion dollars per year? If you look at what most Americans think should be cut (top 2 votes are consistently foreign aid and wages of Congress), this is bigger.
      That said, your point is probably correct. There is more money to made in +GDP (food, pharma, and hospitals — let’s not forget, today, hospitals are paid to take care of the sick, not keep folks healthy) vs. savings. But… this assumption (i.e., yours) is based on the idea that our current situation is sustainable. Is it? I don’t know, but when/if it ceases to be sustainable, it may be too late to do anything meaningful.

    • Mark  March 29, 2013

      While I’m sure there are many stakeholders interested in perpetuating disease, many others, like Big Food as discussed above, are willing to adapt to purchasing desires geared towards overall health, should we ever significantly challange the status quo of medical dogma. I think it’s a bad analysis to say that disease maintenance is economically constructive with a concerted effort on one side to inflict harm and on the other to inefficienty address it. This is the proverbial broken window. If we as a society can unchain ourselves from the productive drain that is chronic disease, we free those who were once invested in our destruction to create and grow our economy elsewhere.

      Or for analogy, if you measure progress by use of gas, it makes sense to say that applying the brake and gas pedal simultaneously is advantageous, and to release the brake would be bad for progress. From the perspective of efficiency and distance though, it’s apparent that to release the brake is beneficial for everyone (even the brakes).

      Just a thought.

    • jake3_14  March 29, 2013

      Although not directly quantifiable, you could add the extra productivity of people no longer made sick by following current nutrition guidelines as a benefit. Further, you could add the extra life enjoyment these people would have — not all benefits show up in GDP.

    • Peter Attia  March 29, 2013

      Totally agree. I think these estimates of direct (“hard”) costs are simply the most conservative. But I agree, the cost, even economic, is greater than typically quantified.

    • Andy Lopez  March 29, 2013

      Mark, you’re talking about ‘progress’, I’m talking about PROFITS, they are not at all analogous and operate at contrary and conflicting purposes as do government policy and medical practice. To use your failed analogy properly you must state it as: “Or for analogy, if you measure PROFITS by use of gas, it makes sense to say that applying the brake and gas pedal simultaneously is advantageous, and to release the brake would be bad for PROFITS. From the CONTARY perspective of efficiency and distance though, aka ‘PROGRESS’, it’s apparent that to release the brake is beneficial for THE GAS CONSUMER (even the brakes), but not the gas producer/distributor or the brake manufacturer whose profits would suffer from a shift to ‘progress’ over ‘profits’ by selling less gas and fewer brakes.”

      “I think it’s a bad analysis to say that disease maintenance is economically constructive with a concerted effort on one side to inflict harm and on the other to inefficienty address it.” Hmmm, you mean like… WAR as a huge make work project that also creates huge profits and benefits to ‘some’ at the expense of ‘others’?

      I did not directly implicate “Big Food” although I probably should have, but I’m not surprised you can’t see that since you also can’t see the triumvirate of government policy, the medical establishment and pharmaceutical industry as the ‘broken window’ they are.

  12. Dave Nelsen  March 28, 2013

    I like the quote “The food industry doesn’t care about health, and the healtcare industry doesn’t care about food”. With respect to the food industry, I guess it depends on the toxicity level of the food they produce. If they make a product that causes acute harm then they’re negligent and will be held accountable (think tainted beef, etc.). If they just make addictive food that causes a large portion of the population to steadily get fatter and lose their health, then I guess it’s ok.

    I don’t think there is a conspiracy, but there is a lot of resistance to changing any of the current dietary recommendations. If the government tried to eliminate – say Corn Oil – saying it is unhealthy – the Corn Oil industry would go to the mattresses to lobby their way out of the ban. The change has to come on the consumer side of the equation, and that is going to take a lot of education and a lot scales falling from the collective eyes of those who choose not see.

    • Peter Attia  March 29, 2013

      I think I agree, Dave. Not a conspiracy. Pure economics. In fact, the CEO of a cigarette company lamented a few years ago something like, “We make the perfect product..it’s got great margins, people love it…there’s just one damn problem… one out of six of our customers dies from using it”

  13. Joshua  March 28, 2013

    So if sugar IS addictive and obesigenic, what is the appropriate response? Outlaw it? Sin tax? Impose a use tax equal to the financial cost of treatment for metabolically driven disorders? Stop subsidizing the industry? Nothing? Educate the populace?

    I hate to lay the blame anywhere but on myself, but I kind of feel like I’m addicted to sugar at this point worse than I was ever addicted to cigarettes. I no longer buy sugar in any significant quantities, but I sure do eat OP’s when it’s available. Even so, I don’t want to ban or tax sugar/starch. I’d be satisfied if all subsidies were stopped, and all federal health/education efforts were stopped as well.

    • Peter Attia  March 29, 2013

      Joshua, this is an important question, and not one I’ll address right now. I will throw out some suggestions later. Point is, doing exactly what we’re doing now, if this hypothesis is true, is not the answer. I think I’ll do a post on this topic at some point.

    • Beef Consumer  April 9, 2013

      The response to sugar should probably be akin to the response to alcohol — an excise tax on the product at the producer level. This would raise the overall cost of the product to both producers of consumer foods and to consumers, creating a direct financial disincentive to add sugars to food products. Ending all subsidies to sugar producers would be a good idea for many reasons (as would KEEPING the current tariffs on sugar). In theory the tax would include all possible sugar sources (sugar, fructose, HFCS, and some of the more hidden sugars like “cane juice” and concentrated fruit juices used for their fructose content). And it should be high enough that it would have a meaningful marginal cost — adding 5-10 cents per gram of sugar to the cost of a product.

      Food producers would then be forced to compete with each other on cost and this should drive down the sugar levels in foods and eliminate it where it’s only a marginal ingredient as the excise tax will make sugar-added products more expensive. More expensive sugar-added food products would then be less desirable to consumers, reducing overall consumption.

      It eliminates most of the “nanny state” rules (like Bloomberg’s big drink ban) since nobody is telling you not to eat sugar, it just costs more, and people could still choose to consume it if they were willing to pay. It would probably be more beneficial to low income people since they eat more processed foods and are more cost sensitive.

      And it might have side effects, like increases in research in artificial sweeteners so that they improve in quality, allowing people to still have sweets in their diet without the negative metabolic impact.

    • shargash  April 14, 2013

      Prior to the introduction of HFCS people were reducing their sugar consumption. Sugar was getting a bad rep, and people were responding. Then HFCS was introduced as a “safer” sweetener. I also wouldn’t underestimate the effect of the FDA’s giving sugar a pass. As a starter we need both education and better government recommendations (really, we need a complete reversal of government recommendations). Unfortunately, with the power of agribusiness, that’s going to be very difficult.

  14. Ash Simmonds  March 29, 2013

    Chris Kresser had a rant about the healthcare industry recently after reading an article about it: http://chriskresser.com/thoughts-on-paleofantasy-bpa-toxicity-research-and-book-updates

    “…there was a recent article talking about the superiority of testing LDL particle number, not particle size, like large fluffy or small dense, but the actual number of LDL particles as being the most important risk factor for heart disease…

    …So the quote is:
    “Some have expressed concern that introducing [LDL particle number] into clinical practice will result in confusion to both physicians and patients, and that the public may lose confidence in the healthcare system if cholesterol, which has been emphasized for decades, is challenged as the primary means of risk assessment. ”

    So essentially they’re saying that some doctors are worried that if we tell you the truth, you’re not going to trust the medical system because we’ve been telling you something that’s not true for decades as a kind of justification for not telling the truth…”

    So on the one hand it’s great if we advance the science and THEN apply guidelines, however government and healthcare have actively been saying what to do and what to aim for, rather than just sitting back saying “maybe this is good and this is bad but we’re not sure yet”.

    The point is made no better than The McGovern Report on cholesterol in 1977 – effectively: “we don’t have time to wait for evidence, we don’t know what we should do, but we MUST do something.” – http://www.youtube.com/watch?v=xbFQc2kxm9c

    • Peter Attia  March 29, 2013

      Problematic, isn’t it? It does illustrate the difficultly of getting it wrong, even if unintentional. Not sure that’s an excuse to do nothing, as Chris is right to point out in his piece.

  15. Valerie  March 29, 2013


    can I ask where you got your figures for the yearly cost of obesity and diabetes? Cause if I do some quick math…

    Roughly a third of Americans are obese. Let’s say 100 million people. Let’s use the $200 billion a year in direct costs of obesity. That means $2,000 per obese person per year. That’s a lot of money for having extra adipose tissue. Over a lifetime, that would be, roughly, $100,000 dollars for someone obese from age 25 to 75.

    For diabetes, let’s take 10 million people, $200 billion a year, that means $20,000 per diabetic person per year. Over a lifetime, that means, maybe, $400,000 (for 20 years of diabetes).

    So for someone obese with diabetes, you say they cost half a million dollars more than a lean non-diabetic person? Really? The only way I can imagine coming up with that kind of number is by conflating diagnosis with all the confounding variables. And even that seems like a stretch.

    Do those numbers seem reliable to you?



    • Peter Attia  March 29, 2013

      Oh, that’s actually a conservative estimate. Think of it this way… per capita HC costs are about $8,600 in the U.S. For every person that doesn’t spend a penny per year (i.e., your average “healthy” person), there is someone spending $17,200 per year. This is, of course, not a normal distribution. Not uncommon to incur costs of $100,000 in a year, unfortunately, if complications of disease persist, especially, as you note, in T2D. Remember, patients are largely shielded from these costs. The co-pays and deductibles are not the real spending.

  16. Al  March 29, 2013

    I’ve noticed that a lot of fat people drink diet coke or coke zero or some variation of the diet/zero genre… if it has no sugar and no calories (apparently)… then why aren’t they getting thinner by the big gulp? In fact the most obese women in my office are devotees of diet tea and lean cuisine microwaveable pasta dishes… I literally see them eat and drink lean and diet every day of the year for years and years in a row.. yet none of them seem to be getting better… last year one of them died of a coronary and they had an office party in her honor where they served bagels, (light) cream cheese, dunkin donuts and orange juice.

    • Peter Attia  March 29, 2013

      I’ll let someone else answer this one.

    • Dave Nelsen  March 29, 2013

      Al, I would say that the women who eat low fat high carb are mostly the ones with Metabolic syndrome. My wife ate that way and struggled with her weight for decades. Her new doctor diagnosed her with Hyperinsulinemia, so basically she has too much insulin circulating through her system all the time. Being insulin resistant means that the blood sugar in her body gets stored as fat. Her doctor (& mine as well) has told us that drinking sugar free drinks still raises your insulin levels (although Peter I think has written about that not being the case). These women probably go to see a dietician who tells them to eat Melba toast and no fat. I have an idiot dietician neighbor (very skinny, Insulin Senstive, runs alot) that knows that the only healthy way to eat is low fat. I tried having conversations with her but her mind is closed. She fails to understand that not everyone processes carbs the way she does. I’ve had a neighbor in the past who was an obese dietician. Talk about a tough sell.

      Then again, if these women go online to get health/diet advice – they are generally going to encounter the message to eat heart healthy whole grains, low fat, no salt, etc. Should they stumble upon this blog by accident they are likely to not believe it or think Peter and his ilk are a bunch of conspiratorial heretics. 🙂 If they tell their friends their eating a low carb diet, they will no doubt tell them how they’ve heard that is very unhealthy. The current food pyramid paradigm seems to be self sustaining to all criticism. It’s the same thing that happens if they follow the dieticians advice but are unsuccessful – the dietician blames the lack of success on the person cheating on the diet. Hope this helps.

    • Donna  March 30, 2013

      Wiht a kudos to Dave’s reply… I am one of those obese women who went the route of diet drinks and lean cuisine dinners and low fat….so on and so on. All it was doing was exacerbrating the weight issue. The diet drink is as addictive as the regular versions. It leaves you wanting more. The diet foods leave you wanting more. There is no satisfaction in eating these foods. Dieting this way becomes a vicious cycle because the very foods that supposedly will help you lose weight are the ones that ‘fix’ it so the calroies consumed are fed to the fat cells and not used as energy. If your system is ‘broke’ all the diet food is not going to change that because it is mostly high carb food.
      Dietitians are expected to toe the line unless they are in business for themselves. They don’t dare deviate from the mantra of low fat, no salt, eat whole grains mantra. It’s maddening to have to ferret out information for yourself but in the end, better off for it. If the women in your office went to a dietitian she was probably given advice to eat low fat, and high carb which is the exact opposite of what they probably should be doing. But that can also lead into a discussion of cost. Many of these ‘dinners’ can be bought cheaply. Real food is more expensive and if you are living on a tight budget, it is harder to buy the real food.
      Last thing, the list at the end….every item listed is high carb and high sugar content. And if your system doesn’t handle it well then guess where it goes…..straight into fat cells.
      Peter, diet drinks may not have the same effect on the body but I find I get as much ‘buzz’ from the non-caloric stuff as the caloris stuff so I wonder if it tricks the brain. I find i have cravings for more no matter which one I drink. And either version I find addictive.

    • shargash  April 14, 2013

      Most people drink diet drinks as an attempt to cut down on calories. They (mostly) aren’t doing it to cut out sugar. They think if they cut out a few hundred calories a day, they’ll lose weight. Not only does that not work, it probably will lead to weight gain in the future as the body’s natural reactions to semi-starvation kick in. If you don’t understand why that is true, you should read “Good Calories, Bad Calories.”

    • Mainstream Mom  July 2, 2013

      I’m actually a dietitian 🙂
      This blog is very interesting to me. I’m not convinced everyone needs to do low carb and I know plenty of people who have had great success at managing their diabetes with even a vegan or near vegan diet. However, although I’m pretty mainstream (relatively), I don’t force people to eat a certain thing or maintain a ‘high’ carb diet (at least not high percentage wise). I don’t even care if they eat butter. The main thing I work with patients on, presently, is the WAY they eat. I try to teach my patients to give themselves regular, reliable meals (avoiding skipping meals) and learn how to be mindful/not eat while distracted. I want my patients to really pay attention to the food they are eating and actually TASTE it rather than eat something because it is on some list of ‘good’ food. I also want my patients to consider how they feel when they eat a certain way and let that be of some guidance.

      If they can start to fix the ‘How’ of their eating then we can start to fix the ‘what’ and I, ideally, make those decisions with the patient based on their blood glucose. Now, I say “ideally” because it’s really hard to get patients back in for repeated visits to really WORK on things. And while I’ve had patients who were obese and female who seemed to be doing everything “right” as far as (low fat, low carb, low calorie), quite often patients aren’t following my recommendations for long enough to even evaluate how those recommendations are working. Or patients who have so much going on in their lives, have so much chaos, have such poor emotional coping skills that unless they address those with a mental health professional they won’t do well on any diet plan. So many types of patients, so many variables. Some can’t even grasp the term “carbohydrate” well until several sessions. Most of us dietitians aren’t idiots, and neither are patients, but sometimes patients leave my office and come back without having understood what I’ve told them in the first place.

      And then there is exercise. I realize exercise isn’t going to make a huge difference in someone who is obese if their eating is way off. But working on building muscle instead of just 10 minutes of light walking would be so much more effective–am I wrong here? And when a person is more-or-less immobilized due to knee/back issues, sitting all day long is also not helping their situation.

      Anyway I’m starting to ramble. My point is, not all dietitians are the same, a lot of patients need more than just one visit (but can’t or won’t come for much more), and a lot of patients have other issues that they need help with before their eating will be where it needs to be.

  17. Mark B  March 29, 2013

    LOL. I think all your posts are great.

    Thanks for clarifying, it makes more sense now. It’s the same thing when I ask people who think cereal is good for them because it is loaded with 26 vitamins and minerals, I ask “So if I take a chocolate bar and stuff it with vitamin pills that will make it good for me?” Astonishingly enough some people say maybe or yes.

  18. Eric Anderson  March 29, 2013

    1) Can you ask ne of your contacts at PBMRC about the study on Manoheptulose?
    Studies on dogs show that 5% of calories from Manoheptulose increased the lifespan 30%.
    A study on humans bing done at PBMRC is overdue IMO No results?

    Manohepulose is a 7 carbon sugar found in Avcados

    2) Can you address your thought on intermittent fasting and ketogenic eating? I do both a 36 hour modified fast and 12 hour eating rotocol that is ketogenic from blood and urine testing. Thi IMO I get the autophay of ADF and low protein PLUS the benifits of ketogenoc diet. This was also reported on in a very small study for children with epilepsy. For me the high fat (MCT in coonut oil) helps my fast day which is 4 V-8juices for electrolytes Eric

  19. Sam  March 29, 2013

    It’s interesting how resistant people are to simple logic. I think there is a pretty significant “bias” against obese people, and it is just a lot simpler to label them as gluttonous sloths, rather than considering that the treatment (and indeed the understanding of the disease itself) are fundamentally flawed. What else could explain the bullheadedness of people unwilling to even consider challenges to the current paradigm?

    It doesn’t take a genius or some rebellious iconoclast to see that things aren’t working. And to conclude that maybe, just MAYBE, we might have missed something.

    In either case, I’m glad to have people like you and Mr. Taubes on the case!

    (also I’d love to see/hear the talks that you two gave, especially if Taubes mixed things up from his usual “why we get fat” presentation!)

    • Peter Attia  March 29, 2013

      Well, I’m obviously biased enough to agree with you!

  20. Stipetic  March 29, 2013

    Great stuff as always, Peter. I quite enjoyed it. However, it was the teaser at the top that’s still nibbling on me. How did the presentations go? Did you and Gary push the audience a little (or a lot)? Was it well received? What was Q&A like? I imagine you discussed NuSi; did that go over well?

    Lastly, since I’m curious; did Gary and George Bray hug? 😉

    • Peter Attia  March 29, 2013

      I was alone at PBRC. Gary and I spoke together at BRMC. Very exciting experience at both places. Great Q&A.

  21. JS  March 29, 2013

    Quick question:

    What are your thoughts on the Intuitive Eating approach (Evelyn Tribole)? I feel like this approach is gaining traction, but in light of addictive qualities of sugar, it seems doomed to fail.

    Thanks in advance for your reply!

  22. Ilan  March 29, 2013

    Great post Peter.

    I wasn’t aware of this until recently, but it turns out medicine does have definitive a cure for diabetes and metsyn. The Swedish Obesity Subjects study (a long-term, prospective, controlled trial) found a high rate of diabetes remission and tremendous improvements in the lipid profile of patients who underwent bariatric surgery. Patients who lost comparable weight using a low-fat diet, on the other hand, did not experience such dramatic improvements.

    I don’t think bariatric surgery is the solution for the metsyn/diabetes epidemic- rerouting the digestive tract of over 100 million Americans would cost billions and, like any invasive procedure, it carries the risk of serious complications.

    However, I do think we can learn a great deal about metabolic regulation from this procedure – studies by Blandine Laferrère found significant changes in the level of incretins and other digestive hormones post-surgery. And studies using pharmaceutical drugs that mimic incretins found also improvements in metabolic health. I’d be very curious to see if ketogenic diets exert a similar physiologic effect.

    • Peter Attia  March 29, 2013

      Good point. It seems the roux-en-Y version of this surgery, while not perfect, does have pretty impressive outcomes, not just for weight loss (as initially perceived), but also for reversal of IR. The question is WHY???? Is it the diversion of bile? The change in glucagon and insulin signalling? The reduced food volume? The reduced carb volume? I have a good friend who just had the procedure last month. Amazing results.

    • Ilan  March 29, 2013

      Good questions. There’s a lot of work to be done in this area (and perhaps a doctorate!).

      One of the most understudied aspects of human nutrition – the gut microbiome – also seems to undergo a dramatic shift after RYGB. In a 2008 article in PNAS H. Zhang reported that post-RYGB patients had a significant reduction in H2-producing bacteria and H2-oxidizing methanogenic archaea. The investigators postulated that this disrupted carbohydrate fermentation and thus reduced the production and absorption of short-chain fatty acids and other related compounds.

      My hunch is that RYGB is so successful because it solves a kinetics problem. It reduces the high infusion rate of food engendered by the industrial age which seems to overwhelm our hunter-gatherer metabolic capacity and lead to multiple downstream effects on cell signalling and gut flora composition.

    • Peter Attia  March 30, 2013

      These are such testable questions. Hopefully investigators are busy at work.

    • jake3_14  March 29, 2013

      Didn’t a recent study suggest that the success of bariatric surgery was due to a change in gut microbiota?

    • Peter Attia  March 30, 2013

      Yes, there is a lot of evidence pointing in that direction. An interesting experiment would be to randomize 2 groups to surgery vs. no surgery, but then the exact same diet (including NPO status peri-operatively) for, say, 12 months.

    • Walter Bushell  January 29, 2016

      Dr. Jason Fung has a lot of success with long term almost zero calorie fasting. Fasting lowers insulin which allows fat burning.

  23. Edward  March 29, 2013

    Hey Peter,

    Are you aware of what Robb Wolf is up to in Reno in relation to risk management for the Reno police and fire departments by putting the policemen and firemen and women on low carb, Paleo style diets? He is working with the folks at Specialty Health on this. His posts on the concept of risk management begin with this one: http://robbwolf.com/2012/04/16/paleo-diet-risk-assessment/

    Thanks for all that you do,


    • Peter Attia  March 29, 2013

      Yes, I’m very familiar with this work.

  24. LizinOregon  March 29, 2013

    Great post, though I don’t agree that it is a waste of time to point out the harm unregulated capitalism does to society as a whole. I would argue that the marketplace also suffers from a failure of understanding all of the facts and risks when you consider all of the externalities that are not part of the “cost”.

    Back to the science, I applaud your efforts to speak to the participants in their own language, though I wonder if it is in their “self interest” to participate in research efforts that could so significantly reduce their patient population and their perks from the drug companies. Aren’t they all CEO’s of their own practices?

    I hope your talk was recorded and that we will have the opportunity to see it.

    • Peter Attia  March 29, 2013

      Not sure I understand your second point. Your first point is a fair one. I don’t know the answer. I know my preference, which is responsible capitalism, but since the system is not structured to reward that, not sure what to expect.

  25. jake3_14  March 29, 2013

    “we can’t really fault the food industry for making their products addictive, can we?”

    Yes, we can. Selling products that directly affect our physiology places an extra ethical responsibility on the sellers not to sell anything that they know that distorts our physiology to the consumers’ detriment. That ethical responsibility supersedes their fiduciary to shareholders.

    • Peter Attia  March 29, 2013

      I don’t know…it would for me, if I was running those companies, and it sounds like it would for you, also. But the system rewards EPS. That’s it. They may pay lip service to other ideas, but the when the rubber hits the road, it’s all about dollars. I don’t think it should be…which is why I run a nonprofit, I guess.

    • Vic  March 29, 2013

      I absolutely agree. Well said.

    • Donna  March 30, 2013

      Here is what I thought while reading this terrific post. The meeting described all sounded like a conspiracy to me but really these gentlemen were acting like the business people we expect all business people to act like. Consumerism is what drives our economy. We are always on to the next biggest and brightes thing. To keep profits, comapnies need to come up with innovative ideas. We see that in cars, electronics, clothing, makeup, furnishings. Why would food be any different. When these companies began to make all these different foods to capture the money, do you think, in the middle of it all, that they were purposefully going out to destroy the health of the country? They wanted to keep or expand what brought profits in. The consumer is a fickle creature led by trends. We change cars, houses, furnishings, clothes, etc Why not food too. One year it’s fried onions….the enxt nachos. The companies jump on to these bandwagons. When low fat became the craze, they jumped on it. Now it’s whole grains. Their overall business is to make money. They do it by creating non food foods. After all isn’t 85 percent of what we eat daily not found in natue? So the consumer can drive the companies to create better foods by demanding them and the companies will follow because they want the bottom line. They aren’t the big bad non-ethical bullies. The non-ethical person is the one who cries against it but still buys the products. If you don’t buy it, the companies will change what they make in response.

    • SR  March 30, 2013

      Well, if you want a small glimmer of hope, you could look to the work of John Mackey CEO at Whole Foods. He is one CEO who is at least aware of the multiple constituents that he must serve and not just the shareholders. I won’t defend all of the companies actions, after all they must compromise heavily to thrive in business in our society. Mr. Mackey is also a leader of a group called Conscious Capitalism which is trying to address the problem of corporate responsibility but they are nowhere near mainstream.

      Mr. Attia, this is very random, but have you ever come in contact with the works of philosopher Ken Wilber? His works are very intellectually challenging (at least for me) but your brilliance is more than up to the task. I think an understanding of his integral model could greatly enhance what you are trying to do here. One thing that stands out is the mapping of human development that could help explain why people react the way they do to scientific truth. Anyway, just a thought… much love to you in your journey. You are doing a great thing here.

  26. Vic  March 29, 2013


    Wherein I appreciate your work. I have to disagree with one main statement you wrote:
    “But, I would argue that shy of knowingly suppressing evidence which, admittedly, may be going on in some areas, we can’t really fault the food industry for making their products addictive, can we?”

    In our fleeting little world, we all need to take responsibility for what we do. Coco Cola poisons people, so why can you not blame that company? Or to put it another way, how can you not hold them accountable for their own actions? They choose to sell a product that causes diseases untold. At what point do we claim that a company’s enterprise is damage-causing enough to warrant blaming them for their actions? Similarly, the cancer industry kills people. If you’re unlucky enough to have a close relative or friend go through chemo, you will know that it is a cruel and poor treatment, not only due to the chemo, but also the array of other drugs that come with the treatment that create so much suffering. People are being tortured to death with modern medicine in so many ways. Should doctors, hospitals, and institutions be held harmless because they are just trying to make a living? It’s a dangerous way of thinking.

    Certainly we are responsible for our own health and we can choose not to eat sugar and drink Coca Cola. We can choose not to go the medical route for cancer treatment. This is OUR responsibility, but this should in no way relieve companies and individuals who harm others, especially for profit, from their responsibilities.

    • Peter Attia  March 30, 2013

      Vic, I agree with you 100%, I really do. My point is that we can’t be surprised when people act in their own self-interest, as most do. I’d love to believe that in a low interest rate, minimal regulatory lending environment mortgage brokers would do the right things. A few probably did. But many (enough to blow up the market) didn’t. Same for traders, lenders, and everyone else. So, unfortunately, I’m left wondering if maybe Congress should not have made the rules such that this took place. Clearly, this topic could occupy an entire blog itself.

    • Walter Bushell  January 29, 2016

      But how do you participate in society where nearly all institutions are actively harmful? Right livelihood is very hard to find.

  27. Brad F  March 29, 2013

    I gravitate towards nutrition posts when the terms cost-benefit, risk assessment, Bayesian and upside-downside nestle side by side with Coke, sugar, and fat. Goes down like buttah.

    I cant implore a enough, if you have not read already, an article from HA Dec12. Looks at salt debate from causation vs correlation perspective, but more importantly, how to move forward on policy when uncertainty exists.

    When I read your post above I was reminded of the citation.

    • Peter Attia  March 30, 2013

      Thanks, Brad. Look forward to it.

  28. John  March 30, 2013

    I’m grateful I live in a world that has you and Gary Taubes in it.

    • Jane  April 1, 2013


  29. Garth  March 31, 2013

    I’ve seen figures similar to the ones you cite about the health cost of obesity, but I also read numerous articles that claim the shortened lifespan associated with obesity and diabetes and smoking make the total cost of care lower for the patients who suffer them. even though the annual cost of care is higher. I haven’t yet found an article that settles the issue to my satisfaction.

    • Peter Attia  March 31, 2013

      Interesting. I’d like to see the data.

    • Garth  April 4, 2013

      This is the sort of thing I’m talking about.
      I’m still confused as to why obese people and smokers would have lower end of life care, which is the only thing I can imagine accounting for the cost difference.

    • Peter Attia  April 4, 2013

      Not sure these findings apply to the U.S. healthcare system. I believe these data were from Europe. Also, weight this against the studies the suggest the opposition, and do so based on U.S. data.

  30. Dan  March 31, 2013

    I think it’s both #1 and #2. Even in the ideal setting where you are prescribing carbohydrate restriction to patients, providing sample recipes and long-term follow-up, there are some patients who just don’t get it. I think this is where the “gluttony of obesity” mythology comes from. Some individuals, despite even advanced education, just do not have the mindset to permanently and intensively alter their diet (and in today’s carb-based society, no less is needed). You do your best to counsel these individuals, but they alone decide what to put in their mouths, and they alone will be walking the path to better health (or not).

    So we know what the best dietary strategy is for insulin resistance. We have the tools to implement it. But at the end of the day, if the recipient of these tools is unwilling to modify their lifestyle, then please don’t blame the health care provider or society or big food or anyone else other than the person involved. Many people just don’t get it, and my days of feeling guilty for them are now over.

    (a low carb diet prescriber)

    • Donna  April 2, 2013

      I think many people do get it. There are many factors as to why compliance fails or seems to fail. Many health care providers claim to listen to their patients but under restrictions of time, insurance , etcs. simply fail to hear what the client is saying. Instead of listening and offering advice based on what the individual is saying many providers just reiterate. The client is frustrated to no end.
      All of us liked to be stroked or told we are making headway. Often the obese individual is making strides towards changing but they are not ‘high fived’ but told you should be doing better. It takes a strong person to overcome all the negatvity that has been heaped on and unless you have struggled with obesity your empathy is lacking.
      Social influences, media, et al are extremely strong. The advertising industry, the research indsutry is always looking for ways to make you want that food, that care, that house, that jacket. Mucho money is spent on ‘false’ food to make you want it…. No…. make you crave it. Betcha can’t eat just one is a slogan food companies try to do with each new product. And on the other side we try it, we get roped in and then we demand more.
      It would be great if the healthcare people really listened or were allowed to listen. Insurance many times now dicatates what a provider can do. If you subscribe to a certain point of view then you will extend that point of view to the person you are advising. You may not be able to hear what the other person is telling you which again leads to non-compliance.
      One other factor leading to non-compliance. Many people cannot afford what they should eat on a daily basis. The cheaper food is high carb. Yes, I know people can budget better and many do but they still come up short. If you have two dollars to buy food for you and two kids you are going to buy the cheaper food and feel enormously guilty about it whic in itself can lead to a vicious cycle.
      The problem does not belong only to the person or to society or the healthcare industry or the food industry. It is a personal quest but also a society quest. Rather than saying I blame you for not being compliant and I am blameless, it would be much more helpful to have a conversation with the other person to find out why they are not compliant. Maybe something important got missed. Maybe they heard what you said and didn’t interpret it correctly. Maybe they have time constraints that make cooking food with healthy benefits a ‘not going to happen’. Maybe they have food sensitivities to items on an acceptable list. Maybe they don’t have access to better food. After all supermarkets vary from city to city from suburb to suburb with some having very little ‘real’ food.
      The issue is not one sided. It takes both sides to make it work.

  31. Alexandra  March 31, 2013

    The abusive, blame the stupid, lazy fat patient attitude of medical providers is the main reason that I completely retreated from the medical industry and, except for the eye doctor and dentist, have had zero interaction with a doctor in nearly 20 years… A couple things… People, maybe more often women, are too compliant when being told what to eat and what to do to be healthy by some supposed authority figure, whether it’s a doctor, someone in government, some random person working for a doctor, a TV personality, or even the commercials we see.. we fail to question their knowledge and true motives as we should and we too often blindly go along with what we are told… When the advice fails, we will nearly always blame ourselves and not the advise. This is why, for example, women will keep “going back on” Weight Watchers, etc. even though it hasn’t helped them keep off any weight… they assume the problem is themselves and not the program/advice. There is pressure on women to be feminine in a certain way… we are rewarded for “eating like a bird” or “eating like a rabbit” which is considered feminine, our public/workplace eating will often reflect this in the salads, lean cuisine, and “lite” foods you see us eating. Later we retreat to home and are rightfully ravenous and will head straight to the fridge for something more substantial. I cured my own obesity problem by doing the opposite of what I had always been told…. I have kept off nearly 130 lbs easily for the past 4 1/2 years by eating a low carb paleo style diet with some full fat dairy included… this works and I am healthier than ever… If I ever do see a doctor again, I will be curious to see if I am treated any better than I was as a fat person.

    • Jane  April 1, 2013

      thanks for sharing your insights.
      and congratulations on your weight loss.

  32. grinch  April 1, 2013

    I know you and Gary keep saying that the authorities are saying the science is settled and that positive calorie balance is the cause of obesity, but why is it when I read other sources I get painted a very different picture. Stephan Guyenet has made it clear scientists do not think calorie intake independent of hormonal and brain-related factors will lead to obesity. Gary has dismissed the role of leptin, despite it being the key hormone in body fat homeostasis. But there are over 10,000 publications in pubmed with the words ‘leptin’ and ‘obesity’, demonstrating that there is tons of research in the area of brain and hormones.

    The only people who seem to perpetuate this idea that obesity is sluttony and gloth are the people in the fitness industry, surprise surprise.

    • Peter Attia  April 1, 2013

      The understanding of leptin, which is secreted by fat cells, does not fly in the face of “all calories are created equally with respect to fat accumulation.” It just explains one one that fat cells may regulate appetite.

  33. Jeff Johnson  April 1, 2013

    Spring round-up

    Bee Keepers…….. these people feed their bee’s White Sugar and HFCS

    What could possibly go wrong with doing that ? Here’s a quote –

    “A mysterious malady that has been killing honeybees en masse for several years appears to have expanded drastically in the last year, commercial beekeepers say, wiping out 40 percent or even 50 percent of the hives needed to pollinate many of the nation’s fruits and vegetables.’

    Point of Interest ?

    A few years ago……….. yours truly ate 6 full cups of raw honey in one day – the following two months I ate two full gallons of raw honey – I did not gain a single pound from this – I finally got my fill of honey and no longer eat that much – 1/4 to a teaspoon is now what I eat –

    Apparently – raw honey is not a calorie or even a carb – at least not in normal terms

    Conversely – I ate four big apples a day for a two month period – gained 17 pounds – quite eating the apples and lost 17 pounds in two months – apparently honey bee’s are smarter than apple tree’s or a small slice of apple is all the doctor ordered – not four big apples

    A girl …………I worked with years ago would bring a three gallon jug of sugar coke and a bag of candy – too work – every day –

    She had a normal upper body – but – her thighs were the size of small heifer’s

    small heifer’s – small heifer’s – small heifer’s

  34. GC  April 1, 2013

    Obesity – Landmark Study – Research just published


  35. Arash Ranjbaran  April 4, 2013

    Hello Dr. Attia,

    I’m an Athletic Trainer working with the Athletic Training Institute (ATI) in Bellevue WA. We have utilized your blog and information extensively with the athletes we work with, and it has had amazing results. (Especially the introduction of superstarch to their training regimens) For that, we present a collective thank you.

    I’ve read through many of your articles, and after reading about your struggle with back pain, and subsequent relearning of many things, I began to wonder if there was anything we could do to help. The ATI is the focal point for MAT – Muscle Activation Techniques – in the Pacific Northwest area, and we see back issues on a daily basis (personally I’ve dealt with multiple spinal injuries, lifetime wrestler and grappler, go figure).

    In a similar light to having someone’s unbiased outlook on the science behind food, MAT is, thus far, the most objective and repeatable means of identifying and addressing muscular imbalances and weaknesses. The system is based on current and emerging neuroscience, and is being refined continuously. Ideally, MAT allows the practitioner to figure out causality vs just treating symptoms.

    If you haven’t heard of it, I highly recommend checking it out. I thought I’d never step onto a mat again. I’ve now been coaching for two years, and contemplating competition again.

    I hope this message finds you, I was unable to find an email address to send it to.

    Thank you,
    -Arash Ranjbaran ATC MAT


    • Peter Attia  April 7, 2013

      Arash, I’m a bit familiar with MAT. It certainly makes sense in theory. Are there any clinical trials that have demonstrated the efficacy of MAT over “standard” tissue therapy?

  36. Stephen N  April 5, 2013

    Evening Doctor Attia,

    How would you say the layman is handling this evidence presented by Gary and yourself? I read GCBC back, way back, when NN Taleb recommended him (based on your writings I think you and I read it the same year). It even inspired me to open a site called calorie diamond, kind of a laymans attempt at explaining this mess to the people (I closed it but it allowed me to branch into apps).

    I ask about the lay fellow because in speaking to people, and quite a few high school teens (they are generally astonished at the things I tell them, claiming not to have learned anything important before what I taught them about sciencey things), I have found that they, much like Myself before I started reading supra geniuses like Taleb and Taubes, DO NOT UNDERSTAND THIS IDEA OF EVIDENCE, FALSIFICATION, Feynman style rigor, so the ideas sail several battleships above their head.

    I’ve watched as many Taubes’ and your’s presentations as I can stand and its clear there are doctors everywhere who just don’t get the correlation causation thing. Is the only plan for overcoming this ignorance of what science actually is “to get some smarties in charge to change the government guidelines”? I expect more from my geniuses (you’re one of my geniuses), like tackling this widespread and profound ignorance… Not by telling them they just don’t get it, but by giving them a method to get it… To “get” science at even my basic level.

    Aside all that, you will do this, I feel it. Maybe the 80/20 rule applies, where you reach the “just enough” threshhold and they shame the other 80 into haughtily knowing “this” evidence like they “know” it’s all about the calories today (“”””””). I would love to see an America full of people who know and use the scientific method as a life method, rather than high school science projects.

    Btw, did you get rich off Bitcoins, being referred to them by yours truly? http://countbitcoin.com

    Fight discouragement… everyone on here… Grow comfortable with it, it lives with you, sleeps with you, is related to you, it’s omnipresent… FIGHT IT.

    P.S. In Ancient Rome, genius meant “divine family protector”. They would say “may my genius protect me”. Every person had a divine double, a “genius”, and the genius received an offering of a plate of food at dinner (it would be eaten by servants or slaves after the meal was over). Your plate is on my table, and you’re welcome to it next time you’re in Miami.

  37. Kelley  April 5, 2013

    Love this site. Thanks for all you do, Peter. I look forward to following the work of NuSI. As an aside: while visiting SF several years ago I bought for my husband the very shirt you’re wearing in the photo on your home page–same color, too! Imagine my surprise when I first visited your website and saw that photo. Ah, kindred spirit, I thought.

    Maybe your readers can answer the following: Is there a website or other resource for locating doctors in a certain geographical area who are educated about and sympathetic to the line of thinking presented here and by Gary Taubes? My husband is a type-1 diabetic, diagnosed at age four. He’s well-controlled and healthy. Just turned 50, and is “remarkably well-preserved” (in the words of his ophthalmologist) for someone who’s been diabetic for 45+ years . Good lipid profile, BP, etc. And, I will add, I believe his physical health is greatly enhanced by his awesome mental attitude. He’s mostly a “hakuna matata” sort. But he’s mildly frustrated by the lack of time his doctor spends with him during a typical visit and would be interested in finding a health-care practitioner who is open to the ideas discussed on this website, including getting deeper into lipid profiles, etc. We live in Eugene/Springfield, Oregon.

    Thanks again! Cheers, Kelley

    • Peter Attia  April 7, 2013

      Very funny, Kelly. To your question, the first thing that jumps to my mind is Jimmy Moore’s website.

    • Kelley  April 9, 2013

      Will check out the website you recommend. Thanks again, and keep up the good work. Cheers.

  38. Bong Kim  April 6, 2013

    Please change the color of fonts in your website to black. The current gray color is not clear nor easily readable. I have no idea why you chose gray color in the first place.

    Have you ever bought a book printed in gray instead of back ink? There’s a reason why the default font color is black for a long time.


  39. Kim Michael  April 9, 2013

    Thanks for your great work, Peter.

    I just started on a keto diet, according to Volek and Phinney. I want my family doctor to run a health check on me to establish a health baseline. Being from Copenhagen, Denmark, I am not sure if my family doctor knows which biomarkers to test for when going into nutritional ketosis. I suppose I want him to measure my cardiometabolic biomarkers, inflammatory markers and my lipid profile, but could you help me be more specific as to which output data are relevant?

    Thanks again!

    • Peter Attia  April 9, 2013

      See the cholesterol series for various biomarkers.

  40. Craig  April 10, 2013

    Your comments about risk mitigation and settled science makes it sound like funding has all but dried up for obesity research. Is that even remotely the case? I understand that you are trying to draw funding to the kind of studies that you think are more important, but that is a somewhat different matter than implying that the problem of obesity has somehow been abandoned by the medical research community.

    Also, the pushback you cite seems to be cast in a very binary matter: calories are everything, or they are nothing. Surely, a more nuanced view is possible.

    • Peter Attia  April 11, 2013

      Well, last year the NIH did fund nearly 2000 investigators, but the median grant was under $300,000 (and the mean not much different), so yes, science in this field is REALLY being downsized. Furthermore, R01 funding is down to 6%. To the pushback, these are points are actually MECE. Either fat balanced is determined solely by number of calories or it is not. If you are in the “not” camp, they sure, there are may options, but my point is most are in the former camp. At least this is my experience, which is all I can go on.

    • Jane  April 12, 2013

      What is MECE?

    • Peter Attia  April 12, 2013

      Mutually Exclusive, Collectively Exhaustive — in other words, count everything, but only count it once.

  41. Greg  April 11, 2013


    Long time reader of your websites, although I haven’t checked in to see the latest in a while. I couldn’t help but wonder what your thoughts are regarding the recent study results, highlighted in the main stream media in the past few days, regarding red meat. In other words we may be looking at by product of a biochemical reaction leading to the hardening of the arteries. I’m skeptical, but not dogmatic about my own views either.

    • Peter Attia  April 11, 2013

      See my most recent posts on FB and Twitter in regard to this question.

  42. Peggy Holloway  April 12, 2013

    Peter Attia + Ken Wilber = a force to be reckoned with! I would love to see these nutrition issues analyzed using Wilber’s integral model. Wow. Anyone up to the challenge? Maybe when I retire. I might be up to it, but it would take most of my waking hours for a stretch of time.

  43. Cat  April 12, 2013

    I love this post and agree with it 100%.

    It really ‘errrks’ me when people point the finger at industry. They are simply doing good business are are truly not out to ‘harm’ anyone, they are just out to make a profit and chances are, if you were in their shoes you would probably do the same thing. I believe there are PLENTY of moral and descent human beings with a conscience that work for Coca Cola, the FDA, and the USDA. If everyone would just stop pointing the finger, pick up a little responsibility for themselves, and continue onward toward the horizon in search of better explainations, we would ALL be in much better shape 10 years from now than if we were to simply ‘corner the bad guys’.

    When it comes to Bayes Theorem, am I right in thinking that it’s similar to the Observer Effect or perhaps the Double-slit experiment in Quantum Mechanics? When it comes to further research in nutrition and medicine, it’s a little disheartening to consider the fact that our observation of a particular phenomenon influences it’s outcome. Almost as if we see what we choose to see and aim for conformational biases without our knowledge or intending to do so… But that’s a completely different philosophical topic 🙂

    The bottom line is we need more research and more MONEY for research. Simplifying obesity down to ‘calories-in, calories-out’ completely shuts out the possibility for alternate explainations, and although it may be easier and less exausting (not to mention cheaper when it comes to research) to THINK in terms of black-and-white, it’s much more difficult, if not impossible, to actually LIVE in black-and-white while surrounded by a universe where NOTHING is that simple.

  44. Evan  April 13, 2013

    Peter, KC and Wade,

    Update for you all…. and how i made a cardiologist lose a bet?

    Recap, low fat diet for 20+ years (age 18-42)

    Lipids at age 27 (on low fat diet):
    TC:155, LDL 96, HDL 43 TG 82

    Fast forward to age 42 (still on low fat diet)
    TC:221, LDL 158, HDL 42 TG 105

    numbers crept up, same diet, same exercise, etc

    Doc says take statin. Research lead me to low carb.

    Age 43 (one yr on low carb)
    TC:282, LDL 189, HDL 73 TG 98

    Doc scared of LDL, prescribes statin. I tear up script.

    Age 45 1/2 (~2 more yrs on low carb with last 6 months adding more carbs, perhaps 10-15% as per The Perfect Health Diet of Jaminet – helped on constipation, legs cramps etc…..and sticking close to PHD with supplements)
    TC:292, LDL 209, HDL 69 TG 71
    (note LDP-p 2323, with small LDL-p 711, LP(a) 7, LP-IR 10)

    Doc sends me to cardiologist as I say I don’t want a statin and I refer to my great HDL and TG numbers and ratio of nearly 1.0, LP(a) of 7, LP-IR of 10, my 7% body fat, and 120/76 BP.

    Cardiolist says, do you want to take a statin?
    I say No, (of course). And I regurgitate info from the Cholesterol series…THANKS PETER!
    (Doc said I was well read)

    Would you go for a coronary calcium scan?

    If calcium shows up will you take the statin?
    I just say, I’ll take the test.

    Cardiologist called today. Seemed quite upset to give me the good news. ZERO. Nada. Nothing on the scans.

    I said now what?
    Doc says, The right thing to do is take the statin due to high LDL go to a low fat diet and avoid saturated fats.
    Well, your father had heart attack at 50 (but smoked 30 yrs and was overweight), the later (family history) being thrown in my face.

    But I got a zero, shouldn’t I just be retested in 3 yrs or so.


    conversation over…..

    question: Did I make the right call?

    • Peter Attia  April 13, 2013

      Wow, Evan…quite a story! Thanks for sharing. I wish I could dive into the nuances, but I can’t give medical advice, obviously. I would say the following, though. A zero on calcium at age 45 is very good…but calcium scans can be misleading if the plaque is not calcified. If you really want to be sure, perhaps consider a CIMT. Also not a perfect test but, when coupled with Ca CT, inflammatory makers, starting to get pretty good…

    • Evan  April 13, 2013

      Thanks. I did ask for the CIMT sonogram, but cardiologist said how about calcium CT (prob assuming I would score 1+ and lose the bet). I will ask again……perhaps.

      A few things nag at me.

      1. Are my good results actually just the result of being on a low fat diet for 20+ yrs? And any bad effects of being low carb (almost 3 yrs) have not taken hold?

      2. Am I playing with fire or a ticking time bomb with ldp-p of 2323?

      3. Was the addition of the Linus Pauling protocol beneficial….the science does make sense. Collegen repairs, and animals which can manufacture their own Vit C do not get CHD. Plus lysine binds with LP(a) etc.

      4. Perhaps a baby aspirin is my safest bet to keep inflammation at bay?

      5. Do I stick with the same cardiologist? Or based on what I heard from him imply he is set in his ways…..?

      6. When is the much awaited part X of the Cholesterol series coming?

      Oh, and I am over 45 1/2, so a Zero is even better!

      Again, thanks for the Cholesterol Series Peter, I read all 9 parts again before my appt. Brings back my organic chemistry days (Chem Eng degree).

    • JohnK  April 14, 2013

      HI Evan –

      I’m no cardiologist, but I happen to be in the care of a very good one who specializes in a particular congenital cardiac condition which I am afflicted. I’ve got about 10 years on you, and I have had roughly the same experience/conversation that you’ve had with yours. I refused to take statins, as I’ve had about the same cholesterol levels my entire life no matter what type of diet/lifestyle I’ve been living. Why my calcium score came back at zero, my Doc stopped trying to push the statins. Also, my numbers have been improving since the 1.5 years I’ve been LCHF.

      It was pretty funny – I got the calcium scores from the lab before the Doc called to tell me what they were. He says “Your score was good.” Any then I asked him if it could have been any better, and he was forced to admit it couldn’t. I think he was a bit disappointed that he couldn’t convince me to get on statins based on my calcium scan.

      However I will continue to see him because he’s apparently the world’s best for my condition, and generally knows his stuff. But I wouldn’t call him a cutting edge nutritionist by any means. We apparently have agreed to disagree – and my 45 pounds of weight lose has been hard for him to argue with.

  45. steve  April 13, 2013

    hi Peter, I love your blog and have referred several friends to it. I just got interested in health last year after gaining about three inches around my gut over the course of the last 15 years (I’m 45 now). I generally ate a SAD diet though on the “healthier end”; I.e. lots of veggies, very little fried foods, and very little wheat. Still, blood tests showed that I was borderline and doc wanted to watch my cholesterol. A friend of mine, a raw vegan, got me interested in diet and health so I decided to do an experiment on myself. I largely followed the 80-10-10 with about 90% compliance. After 8 months, a blood test showed fabulous LDL and TC, I lost 8 lbs, and about half of my 3 inches of belly fat. My TG/HDL was around 2.5. good but not great. Now I am experimenting with a low carb Paleo. I’m generally around70% fat, 15% protein and 15% carb. I’m only 1.5 months in but have already dropped another 6lbs or so and another inch of gut fat – its now almost gone. So both diets have done wonders for me so far.
    So this got me thinking-is it possible that macro nutrients are overrated and it is the QUALITY of those macro nutrients that matter? The things I did under both diets are to cut out added refined sugars and processed foods. So the quality of my food went up significantly.

    One thing I have learned in my short adventure into nutrition land is that people can get religious about diet and there are testimonials to support a range of diets. Perhaps the mediating variable is not macro nutrients but quality of those nutrients? Anyways, I pose this only as a question with a lot of humility because I know I am still a newbie on all of this. But I am curious as to whether people have looked at it from this angle in a scientific way.

    • Peter Attia  April 14, 2013

      I agree that quality is a huge issue, but how to define “quality?” Is it micronutrient based? The real issue, though very difficult to quantify, is how does food turn on and off gene expression? How does it impact hormones and enzymes in the body? Because most folks can begin to contemplate this, it’s easier to collapse into a discussion of “eat this, not that,” without any nuance.

    • Sofie  July 4, 2013

      The impression I’m getting is that vegan generally works short term, but that many people get problems with it long-term. Many, especially women it seems, find themselves with major physical problems after several years of veganism – bone, muscle, brain, teeth, skin, hair, basically anything. Seems to me we’re adapted to surviving a hunting draught, but not to living without animal foods. And what you don’t eat can be more important than what you do eat, at least short term.

  46. Evan  April 14, 2013


    Can clinical hypothryodism play a role in increased Lipid numbers? Can this go undetected with normal tests due to the vast ranges that are considered normal? All my TSH, Free T3 and T4 in range.

    When one looks at the symptom list, it’s quite easy to admit to more than a handful. Are they just a laundry list of vague common symptoms?

    Weakness, lethargy, fatigue (yes, but we all want naps during the day)
    Dry skin ( YES)
    Coarse hair (yes)
    Cold intolerance (yes, extremeties)
    Constipation (yes)
    Weight gain (no)
    Muscle cramps (yes, due to low carb?)
    Edema of eyelids, face, legs (nonpitting) (no)
    Hoarseness (no, i dont think)
    Hearing loss (what?, i mean no)
    Menorrhagia (uh no)
    Slowing of return phase of reflexes (e.g., knee jerk) (no?)
    Bradycardia (no)

    Are one type of doctor better than the rest (endo vs thyroid vs internal vs holistic) to dig past “normal in the range” test results?

    Still looking for part X of the Cholesterol series!

    • Peter Attia  April 14, 2013

      Hypothyroidism is associated with increased apoB. So anyone with hypothyroidism and elevated apoB should have it corrected. Part X hopefully by June.

  47. Isaac  April 15, 2013

    Peter, Thanks for another great post and the link you shared on the FB page about the article regarding carnitine and read meat. I’m pretty sure I don’t eat a thousand of anything single item/day let alone steaks, so that brought some perspective lol. So I have posted a variation of the question before but thought I would re-visit it. What is your best advice for lean gains while trying to remain keto-adapted? By lean gains I mean muscle mass of course. Thanks!

    • Peter Attia  April 15, 2013

      Needs its own post. Complex topic.

  48. Bret  April 16, 2013

    Great post, Dr. A.

    The odds our community faces are indeed disturbing. The current “wisdom” is so ingrained in society that it is difficult to find even a layman (to say nothing of a professional) who does not firmly possess those pushback attitudes you articulated. Most people just cannot seem to bear to let themselves conceive of the possibility that countless professionals and experts in the mainstream could be wrong.

    Along that note, this whole debacle of poor nutrition science might end up having a silver lining for us in the modern western world. Once the majority of people realize that all of the dietary advice they’ve been spoon-fed over the last 40 years has in fact been wrong (I am optimistic it will happen eventually), we will hopefully see a surge of societal awareness of how to identify good vs. bad science, how to recognize and combat confirmation/selection bias, and the importance of polling a diverse crowd for advice, not just the “experts.”

    • Peter Attia  April 18, 2013

      Bret, I like how you’re seeing the glass-half-full…

  49. AHW  April 17, 2013

    I am astounded by the degree to which people today consider lifetime medicalization necessary for what they call “health” in the absence of what I would call “biological normality” or what we USED to consider “health.” My own family take it for granted that getting older means getting fat, losing mobility, and ultimately getting either cancer or heart disease. This is what is now considered “normal aging.”

    When you suggest that by making these very simple, easy, and certainly not unpleasant dietary changes the Paleo camp advocate you might be able to AVOID falling victim to these conditions, people often become openly hostile. My own family think I’m a certifiable nutter for refusing gooey desserts, and think I’m off-base by likening sugar to the effects of alcohol, tobacco, or opium. On the other hand, they think I’m committing slow suicide with my bacon and eggs! I do NOT trust the medical industry, and am highly motivated to avoid the slippery slope of medicalization–in itself considered counter-cultural insanity today among most of the earnest & concerned types!

  50. Brenda  April 17, 2013

    HI Peter; love your blog and as the previous commenter said thanks for sharing Chris’ article on carnitine and red meat. I find some comfort in your articles and the comments as I have very hight cholesterol and like many refuse to take statins. I am curious to know if you have any comments regarding a recent article in Lancet regarding heart disease in 4000 year old mummies; http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60598-X/fulltext. I found it fascinating. Anxiously awaiting Cholesterol part X as well. Thanks

    • Peter Attia  April 18, 2013

      I don’t. I think Stephan Guyenet did a piece on it, though.

  51. LeonRover  April 18, 2013

    Hi Peter
    This post nicely illustrates the use of Bayes Theorem in decision-making.
    Shall you be using Bayes in Part X of the Cholesterol Series ?

    John Briffa referred to this study – http://www.ahjonline.com/article/S0002-8703%2808%2900717-5/fulltext – which presents Lipid levels of 137,000 Coronary Hospitalisations.

    What should be attitude of a Bayesian Decision Maker when faced with these Lipid Histograms?


    When one sees these data, and also notes that 21% of those hospitalised were taking statins, it is clear that CETP Prevention Program is flawed.


    • LeonRover  April 18, 2013

      PS For CETP pls read ATP!!

  52. Evan  April 19, 2013

    Can’t help myself, but I am totally dumbfunded when people say that they or whoever “eats a healthy diet”.
    Frist thing that pops in my mind is, low fat, whole grains, egg whites, high carb diet….blah blah blah – and that is what it usually is.
    Next thing I think is “Evan, just keep your mouth shut”

    The best is when it happens at dinner, and I say, “me too, it’s important to eat the right foods, waiter, I will have a double cheeseburger with bacon, and put an egg on that……but no bun please, I am trying to eat healhty.”

  53. Susan  May 5, 2013

    The NYT article reminds me of the meeting that Elizabeth Warren describes having with the top executives of a large bank/credit card operation. Her whole presentation was on how they could better screen credit applicants and avoid defaults. She was stunned when they didn’t react to her suggestions. One of the execs pulled her aside after to tell her that they had no desire to tighten up their approval process – the riskier customers were the ones who made them the most money. Not a perfect analogy, but not too far off the mark.

  54. MaryAnn  May 7, 2013

    Peter, Thank you for speaking truth about heart disease. I lean into a paleo diet (oceans of veggies) and am wondering if you would consider writing on vitamin K2 and choline. I am 52 and have many friends that are struggling with bone loss. What I am reading is that most women my age are deficient in choline (needed for cell membranes and thus absorption of nutrients into cells) and vitamin K2. It seems that lack of K2 could be causing calcium to deposit in blood vessels and tissue instead of bones. Any thoughts? Mark Sisson (Mr. Paleo) promotes offal, grass fed meats, and free range eggs – all containing significant levels of choline and K2. I can’t help wonder if this is also part of the heart disease/bone density picture. Also, could lack of choline be making us hungry because we are malnourished? Thanks!

    • Peter Attia  May 7, 2013

      I think a lot has already been written about this. Check out Chris Kresser’s stuff, in addition to Mark’s.

  55. Nikki  May 18, 2013


    I just discovered you and I’m reading through all the material. I have tried similar things that you have noted to do. But, I’m going to give it another shot. I’m beyond frustrated with my body at this point. I’ve tried so many things. I even did a combo of paleo diet and cross fit for 4 months with a personal cross fit trainer and didn’t lose weight or inches. He was baffled and accused me of not following the diet. I would leave there in tears. My husband was doing it with me and he lost 25 lbs. I ended up quitting because it wasn’t working. I have over 100 lbs to lose. The only thing that has worked the last few years is a 500 calorie diet and even though that’s short term, emotionally it’s so hard. I’m not hungry on it, but mentally I just can’t do it. I’m very carb sensitive. So, usually I go very low carbs. I’m more of a protein person. I think at this point part of it just mental. I’m really picky and don’t like a lot of veggies. I tend to eat the same thing over and over which I get tired of. So, I do better on protein/fats then carbs. But, I can’t stay like this. I wasn’t always fat. I don’t even eat a lot of carbs (I’ve already cut out pasta and breads and don’t really miss them. I do like potatoes though. And I rarely eat rice anymore). I just am probably eating the wrong things. I’m not a person who snacks all the time or who is hungry all the time either. I even have a hard time using all the points on WW. I have an inflammtion problem in my body (HLA-B27 – Ankylosing – no back pain anymore just Uveitis) So, I’ll go over your site and make a plan and get back to exercising. Thanks for all of the information. I don’t know, for some reason I’m feeling some hope creep up.

    • Richard S  May 22, 2013


      I feel your pain.

      As I see it, there are 2 ways to lose weight. Both involve changing what you eat. Exercising more helps, of course, especially with happiness and overall fitness. But to lose a lot of weight, you have to change what and how you eat. There’s no way around that.

      Of curse, one way to lose weight is to eat less — to get significantly fewer calories. We all know that works. And the less we eat, the faster we’ll lose weight. But that’s also hard to do, especially for a sustained period of time.

      The other way to lose weight is to cut out carbs. And I mean to really CUT them from your diet — all the way out. Think of it this way, you can eat as much as you want — all the fats, protein, and veggies you want — and if you keep carbs to fewer than 20 grams a day, the pounds will drop off. Seriously. That’s what I did. I’ve lost 35 pounds and I no longer need cholesterol or BP meds.

      You can do it. Just find foods without carbs that you like to eat. Ignore the potatoes and other carbs that you should avoid. Pretend that you are allergic to them, because in a sense you are. Focus instead on the tasty non-carb foods that you can eat. After a while, you’ll be losing weight, you’ll feel great, and you won’t really want any carbs. Then you’ll be on a roll and can lose as much as you want.

      Anyway, that’s what has worked for me. Good luck!

    • Ellen Urciola  May 23, 2013

      Hi Niki,
      For what it is worth, I to had over a hundred pounds to lose. Two painful things I came to realize; one all carbs had to go for me, second, I had to give up all dairy (except steamed heavy cream in my morning Starbucks). Also, my scale keeps telling me I have not lost any weight However, I have dropped three pant sizes (22 to a women’s 16). I don’t why this is happening, maybe water? anyway I also have to keep my calories of fat and protein (to a fat 65-70% and my protein 30%. If don’t feel a little bit hungry before I go to bed I know I ate too much.
      I have noticed different groups of people who respond to this blog lose weight lose weight using the same method fat to protein, but in varying degrees.I happen to be (unfortunately) in the no carb, moderate fat, very low protein, even less dairy group, which translates to less food for me. It is definitely a journey, stick with it, it is worth every ounce of effort!

    • Nina  May 23, 2013

      Hi Nikki,

      I would like to join Richard & Ellen in encouraging you to join the community of low/very low carb-ers. It really works & you will feel better, but you need to cut out all carbs & artificial sugars……just stick with fat, protein, & greens. I, like Ellen, find I (mostly) have to limit my dairy to my morning coffee with 35% cream. It’s also my impression that women have a more difficult time dropping weight than men, so you can’t measure your success against your husband’s weight loss.

      Sometimes I go off-plan & am amazed at how easily I can revert to my “addiction.” It only happens when I’m over-tired or off-balance emotionally & I can always trace back a preceding imbalance in the ratio that I know works for me…….but you just get back on track because it’s the only healthy way to eat.

      I wish you luck and success!

  56. daniel  May 22, 2013

    At “I recently gave the keynote address”, i read “I recently gave the ketone address”. I guess i’m loving ketones a lit bit much…

    • Peter Attia  May 22, 2013

      I’m actually giving a ‘ketone-keynote’ address next Thursday at IHMC… funny you mention it.

  57. Lara  July 2, 2013

    I am curious to hear the thoughts on the declaration that obesity is now being considered a disease? Sorry if you have commented previously, I only just found you 🙂

    I am type 2 – struggle with weight (since I was a child). Was born with cancer. Family on both sides for generations have/had diabetes. I was told “I was destined to get it”.

    Only just saw your TED vidoe – was very eye opening. Finally a medical professional who does not shove more and more medication down your throat. Who addresses the coffee table rather than the bruises.

    Every time I see the Doctor more medication is prescribed. It’s become too stressful to go so I do not go anymore. The stress is worse than the diabetes

    I digress..

    • Peter Attia  July 2, 2013

      Lara, I commented on this in my TEDMED FB Q&A recently. You can probably find it on their FB page.

  58. Mickey  July 2, 2013

    Dr. Attia – as always, very refreshing blog.

    I have recently been listening to Dr. Phinney/Volek, and they suggest this Well Formulated Diet where a body’s protein and carb requirement are almost constant (depending on the body composition, age, etc.). The variable, if you will, is the fat intake. For someone like me, the protein requirement is probably around 100g/day. It makes sense, but I was wondering if the protein intake needs to be accompanied with fats? If I consume a protein shake in the morning, (the ones I have are mostly low fat/low carb); would it result in an Insulin reaction from the body?

    In other words, choice (1) be preferable over (2)? Do you think choice (2) would result in an Insulin reaction if it’s mostly protein breakfast:
    1. 3-4 meals with 25g protein each, and the rest in fats
    2. Protein-rich breakfast with 50g protein (very low fats, carbs); protein-rich lunch with 50g proteins; fat-rich dinner.


    • Peter Attia  July 2, 2013

      Not really sure. May have more to do with catabolic demands (e.g., timing of exercise). From the standpoint of reducing GNG, less protein in one setting may be desirable.

  59. Mickey  July 4, 2013

    Thanks Dr!

    Also, sometimes I just don’t feel like eating – perhaps because it’s late in the day — too close to bed time, or am just not hungry. But I fear if I don’t consume daily requirements worth of calories (~ 2000 kcals), my body will be undernourished, and I sort of force myself to eat a meal. Is this worry unnecessary?

    BTW, your ‘fat shake’ is awesome. On days when I am rushing in the morning, it’s a blessing. One serving in the morning, and it lasts forever! I couldn’t imagine me drinking even a teaspoon of that ‘shake’, forget gulping down 2 cups full of awesomeness 🙂


  60. Karin  July 17, 2013

    I have read “Salt Sugar Fat”, the book that the NYTimes article you have linked to is referencing. It is a great book and I would love to hear your thoughts on it. Have you, or anyone else you know, had the opportunity to read it?

    • Peter Attia  July 17, 2013

      I have read it. It’s interesting enough.

  61. Karin  July 17, 2013

    I will add another little comment here…regarding “blaming the industry”.

    I have to disagree to a certain extent on the idea that the companies are just doing good business. I don’t think industry is completely at fault but some responsibility falls at their feet. We have to draw the line somewhere. Businesses that are not putting the health and welfare of the public can engage in whatever good business they want to drive up their bottom line, I am all for that. Any business that could put the health and welfare of their customers at risk has a greater responsibility than their “bottom line”. If they are going to use the slogan “part of a healthy diet” they had better well be healthy.

    So yes – industry is part of the problem. They have a vested interest in making sure the public continues to eat their products…in larger quantities. They have billions of dollars to make sure of this, and billions of dollars at stake. You’d better believe they will do everything possible to make sure their products are seen as “healthy and nutritious”. Do you think with a few billion dollars, they have been able to and continue to be able to do this??

  62. Dmitri  August 2, 2013


    Do you know of any research partnerships or other active efforts to engage insurance underwriters in this kind of debate? Our (US) system is set up so that insurance companies end up managing the risk of outcomes for the decisions made by our political leaders (including Govt and Medical community political leaders, I don’t consider the AMA a private organization).

    I’m interested in finding out more about that – looking at the business case for LCHF.


    • Peter Attia  August 2, 2013

      Yes, but I’m not sure I can speak about it. Good news is, they are very interested in this discussion and probably have more incentive to prevent illness than providers, from an economic standpoint.

  63. danimal  August 20, 2013

    I have an economics degree. Maybe it’s cuz i was stuck on just textbook assignments and not engaged with the real world but I never understood what these costs actually meant until after I GRADUATED and started looking at the politics of healthcare from an austrian economics perspective, which heavily discusses the role of the FEDeral Reserve system.

    I would venture to assume that most ppl in this country also don’t GET what it means to save billions of dollars since they think we can just print out more money without impunity. I’m not sure if your blog posts talk about the economics of healthcare but that might be an idea

  64. Guido Vogel  September 19, 2013

    Hi Peter,
    Claude Bouchard studied a group of twins on a diet of overfeeding. Main results were that there was quite some variation between the different pair of twins, but not so much within the pair of twins.

    This shows that individuals respond differently to overfeeding and that genetic make-up matters. However, it does not tell us anything about the possible impact of macronutrients in the diet.

    Is there any follow-up study done that did the same overfeeding in terms of calories but where one of the twins is fed LCHF and the other HCLF, keeping protein constant? It would be interesting to see whether there are difference between each of the twins. I am aware of Tim Noakes’ study, but that is only one pair of twins.

    Is this something that is in the pipeline of NuSi?

    • Peter Attia  September 19, 2013

      Yes, these were very interesting experiments, indeed, and I’ve spoken at length about them with Dr. Bouchard (a fellow Canadian, no less). I’m trying to refrain to discussing NuSI too much in the blog. Gotta separate my personal life a bit.

    • Hemming  September 19, 2013

      Hi Guido,

      Sam Feltham at http://www.smashthefat.com is currently doing an experiment on himself eating a HCLF diet of 5800kcal/day. He previously did it with LCHF. You can read all about his experiments at his site. I’m not at all saying this is proof of anything or a scientific study. I think the point is more that he wants to challenge dogma.

  65. Guido Vogel  September 19, 2013

    Hi Hemming, thanks for the link. Saw that one via Andreas Eenfeldt’s DietDoctor website.

    Hi Peter, I understand that don’t want to mix up or create/maintain threads about NuSi. There is no discussion forum there and I haven’t seen updates of the site nor did I receive any communication after my donation. Not to complain too much, but it would be nice to get some insight what has been going the past year and what’s on the planning. I trust you guys, but curious to know what’s going on!

    • Peter Attia  September 19, 2013

      Working to address this, but down the list relative to a few other priorities.

  66. Jonah  April 27, 2014

    I went on a camping trip this weekend with the outdoor rec. program at my university. I typically follow a rather low carb diet, and was aware that I had to suck it up and eat whatever they cooked. However, two days with fellow college students was quite the illuminated experience. For breakfast we ate pancakes with powdered sugar and syrup (fried in vegetable oil). We went rock climbing during the day so it was picnic style. This included chips and dip, pretzels, party mix, and a ridiculous amount of crackers. By the time dinner rolled around we were all hungry so we were watching people prepare the dinner (Chicken Alfredo). The guy put a stick of butter in the sauce and added heavy cream and everyone started freaking out. When people were eating I heard comments such as “I can actually feel my heart beating in my ears from all of this butter”. Or “There is 1000 calories in each carton of heavy cream! I’m not going to eat for a week”. The people were complaining the whole weekend about their weight, and it was concerning. I didn’t know the people well enough to try to explain to them that they were eating the wrong foods. After making a comment about their sugar laced honey nut cheerios going to “lower my cholesterol after all those fatty noodles last night”, I gently stated “I don’t think thats how those things work” (referring to your arteries, as if one fatty meal will clog them all up and some cheerios will loosen them up or something). They militantly got back into a some argument about calories and fat.

    Anyways, the people were genuinely concerned about their health and gaining weight, but were cock-sure that they knew everything there was to know about food and health. I think that people genuinely care about their health and are doing what they can to lose weight. Except that their prescription is devastatingly wrong. It is so easy today for someone to get brainwashed by the media today about anything health related. Most people have no idea about what the nature of science is, or how to think critically about what the media tells you. Even if I was to show those people this blog, they have been told their entire lives the exact opposite information and wouldn’t even read on to hear any evidence. It is very difficult to find good information, let alone weed out the debates to find some truth. It is deeply disturbing how many misconceptions the layperson has about what they stuff in their faces. The public needs to be informed about what to eat. Maybe an affective method would be leak some truth in t.v. commercials, or maybe even pop music. I’m sure if we payed Taylor Swift enough she would sing about coconut oil and cholesterol.

    Another point– I think Mark Twain once said “It’s easier to fool someone than it is to convince them they’ve been fooled”. Or something along those lines.

    • Vicente  April 28, 2014

      Hi Jonah,
      even people who are really fat and sick, they think they are eating the right thing. And we are crazy for eating a lot of fats because they know it will make us sick. We are killing ourselves.

    • willam reichert  February 25, 2015

      You may be right. Recnelty I read a study in the journal Diabetes. Dec 2009 pp2741-2727. They gave 2 groups
      a diet insisting of a 500 calorie deficit diet.One was high fat. One was high carb. After 8 weeks both groups lost same amount. ( 7 kg) The high fat group developed evidence of increased arterial stiffness which is considered a sign of cardiovascular risk for high Bp. It is an interesting study. The high carb group lost more lean body mass. Check it out for details.

  67. Diana  July 10, 2014

    You refer to sugar addiction, but what about the broader topic of “food addiction”? There are 12 step programs for food addicts, much written on the topic, and many people who are overweight by 100+, 200+ and more pounds. Is it strictly biological, or are there psychological and spiritual factors that need to be explored and worked on in order to be anywhere need a “normal” weight? What is our addictive nature that results in food obsessions and gaining/maintaining extremely high body weights? Thanks.


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